The liver shows diffuse hyperreflectivity with geographical areas low echogenicity in segment 5 adjacent to the gallbladder fossa - these are highly specific for benign hepatic steatosis with associated focal fatty sparing.

A hypoechogenic, circumscribed solid lesion is also apparent in segment II of the left lobe, which was not visible on prior imaging (CT/US). Due to the small size and ideal position of the lesion contrast-enhanced ultrasound (CEUS) was recommended for further evaluation instead of cross-sectional imaging, due to its superior temporal and spatial resolutions.

As with any other CEUS exam the lesion was first confirmed and measured and the entire liver was scanned using B-mode US.

After the injection of IV contrast (SonoVue) the lesion demonstrated marked hyperenhancement during the entire arterial phase (see cine loop), while it remained isointense throughout the portal and sinusoidal phases. Most importantly no washout could be observed. Altogether the findings are characteristic for a flash-filling hemangioma, and do not support malignancy. Prior oncological control CT exams were performed with only venous phase acquisitions to limit radiation dose, which offers an explanation why the lesion remained undetected. Further regular follow-up of the patient is nevertheless warranted.

The geographical low echogenicity areas remained isointense through the entire exam (not shown) in line with focal fatty sparing.